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November 16, 2009Workshop I

Common Mental Health Concerns In Older AdultsA Series of Four Workshops

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Understanding Dementia

Bernie Seifert, LICSW

Northern New England Geriatric Education Center

[email protected]

Common Mental Health Concerns In Older Adults

A Series of Four Workshops

Northern New England Geriatric Education Center at Dartmouth Medical School

November 16, 2009 Understanding Dementia

Upcoming workshops:

December 14, 2009 Substance Abuse and Misuse in Older Adults

February 1, 2010 Hoarding Behaviors in Older Adults

March 2, 2010 Understanding Depression in Older Adults

Overview:

Cognitive functioning (“normal aging” vs. dementia) Various types of dementia Screening for /assessment of dementia Helpful interventions when interacting with

individuals who have dementia

Northern New England Geriatric Education Center at Dartmouth Medical School3

Dementia Diagnostic Criteria*

Weakening of the Memory

Deficit in at least one: Aphasia, Apraxia, Agnosia, Executive Functioning

Impairment in social or occupational functioning

Gradual onset and continuing decline

* DSM-IV-TR (Statistical Manual of Mental Disorders)


Dementia

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Most cases of dementia in older adults are Alzheimer’s Disease (approx. 60% to 80%)

Next most common type is Vascular Dementia (10% to 20%)

The rest form a long list, including (not limited to): AIDS (HIV Infection), Lewey Bodies, Parkinson’s Disease with dementia, Frontotemporal Dementia (Pick’s Disease), etc.

Dementia


3.4 million Americans have dementia2.9 million have Alzheimer’s Disease5% of people 71-79 y.o. have dementia37.4% of people 90 y.o. have dementia1 in 7 of 71 y.o. and older have dementia

Diagnosis of AD


Clinical

Criteria:1. Gradual & progressive decline cognitive function2. Recent memory impairment with eitherLanguage disturbance Skilled motor function decline (without weakness)Visual processingExecutive function decline

3. Not due to psychiatric, neurological, systemic disease4. Not delirium

Early Diagnosis


Only 3% are diagnosed in the early stage

25% are diagnosed in moderate stage

Many are under diagnosed; even more under treated

Normal Aging –vs- Disease


Early DementiaMemory & concentrationMood & Behavior

Late DementiaLanguage and speechMovement and coordinationOther symptoms

Normal Aging –vs- Disease


Alzheimer’s Disease Normal AgingForgets entire experience Forgets part of an experience

Rarely remembers later Often remembers later

Gradually unable to follow written/verbal directions

Usually able to follow written/verbal directions

Gradually unable to use notes as a reminder

Is usually able to use notes as reminders

Gradually unable to care for self Is able to care for self

Typical Aging

Executive Functioning Short-term memory Confrontation Naming


Hey…Don’t blame it all on aging or dementia!


Some behaviors are lifelong May be exaggerated due to stress, depression, etc. Ability to cope and flexibility is characteristic of

person, not aging Personality does not change with age unless

modified by disease

Mild Cognitive Impairment (MCI)


Memory problems and mild impairments,

but able to function quite well in daily life

MCI – Mild Cognitive Impairment


Useful in identifying persons high risk for AD Symptoms may include:

Memory impairment & one of following:disorientation & impaired judgment changes in mood speech disturbance difficulty with task completion

Different types of MCI


Amnestic MCI Multiple domain MCI Single non-memory domain MCI

Risk factors for MCI High Blood Pressure High Cholesterol Diabetes Osteoporosis Obesity COPD Smoking Head Injury


MCI Screening:


Neuropsychological testing Clinical judgment Screening tools such as MMSE, Mini Cog

Vascular Dementia (VaD)


Also known as Multi-infarct Dementia (MID), Vascular Cognitive Impairment (VCI) , & Cognitive Impairment-No Dementia (CIND)

10%-20% of all dementiasCommonly thought of as the 2nd most common

dementia

Vascular Dementia


Increased risk associated with stroke

Differences in presentation: VAD and AD


Executive dysfunction more impaired (abilities include cognitive flexibility, concept formation and self monitoring)

Memory is less impaired (or not impaired)

Treatment for VaD:


Minimize risk factors (What is good for the heart)Lower BPLow blood sugarsAspirin

Possibly use medications (donepezil, galantimine, rivastigmine, memantine) as AD – similar benefits. Need to weigh against cost/side effects.

Other Dementias…

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Frontotemporal Dementia (focal atrophy of frontal and temporal region of brain)Gradual progressive behavior/language change (highly

inappropriate social interactions)Occurs between 35 – 75 yr olds

Dementia with Parkinsonism & Dementia with Lewey Bodies:Gradual progressive dementiaFluctuations in cognitive functionPersistent visual hallucinationsSpontaneous motor features

Clinical Features of Lewey Bodies Dementia is essential to diagnosis Plus 2 of the following:Cognitive FluctuationsVisual HallucinationsParkinsonism



Frontal lobeParietal lobeTemporal lobeOccipital lobeCerebellumBrain Stem

Reversible Dementia (“pseudo dementia”)


Medication Induced Alcohol related Metabolic disorders Depression

Screening for Dementia:


Mini Mental State Exam (MMSE) Mini-Cog

Case: “Marion”


81 year-old, widowed 15 years ago; lives alone in same home for past 40 years.

Diabetes, hypertension, arthritis, high cholesterol, macular degeneration.

History of depression following her retirement and husband’s death.

Discontinued alcohol use in recent years. Denies current use.

Has involved family living close by.

Family concerned about recent incidences and question recurrence of depression.

Why use the MMSE?


Tests 5 areas of Cognitive Function:OrientationRegistrationAttention & CalculationRecallLanguage

5-10 min. to administerSource: Folstein, 1975

MMSE Limitations:


Cannot diagnose case for change Relies on verbal response, reading and writing

Source: Folstein, 1975

MMSE – 5 Areas:


Orientation Registration Attention & Calculation Recall Language


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The Mini-Mental State ExamPatient___________________________________ Examiner ____________________________ Date____________Maximum Score

Orientation5 ( ) What is the (year) (season) (date) (day) (month)?5 ( ) Where are we (state) (country) (town) (hospital) (floor)?

Registration3 ( ) Name 3 objects: 1 second to say each. Then ask patient all 3 after you have said them.

Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record # trials: ___________

Attention and Calculation5 ( ) Serial 7’s. 1 point for each correct answer. Stop after 5 answers.

Alternatively spell “world” backward.Recall

3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer.Language

2 ( ) Name a pencil and watch.1 ( ) Repeat the following “No ifs, ands, or buts”3 ( ) Follow a 3-stage command:

“Take a paper in your hand, fold it in half, and put it on the floor.”1 ( ) Read and obey the following: CLOSE YOUR EYES1 ( ) Write a sentence.1 ( ) Copy the design shown.


Scoring for the MMSE


24 - 30 “normal” range

20 - 23 mild cognitive impairment

10 - 19 middle stage impairment (moderate)

0 - 9 late stage impairment (severe)Source: Folstein, 1975

Mini-Cog – 3 steps:


1. 3-item - repeat2. Clock-drawing Test (CDT)3. Recall of 3 items

Source: Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in

multi-lingual elderly Int J Geriatr Psychiatry 2000; 15(11):1021.

Why use the Mini-Cog:


Simple, effective and easily administered Relatively uninfluenced by education level Detects cognitive impairment in earliest stages

Source: Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia

screening in multi-lingual elderly, Int J Geriatric Psychiatry 2000;

15(11):1021.

MINI COG – CDT

1) Inside the circle, please draw the hours of a clock as

they normally appear

2) Place the hands of the clock

to represent the time:

“ten minutes after eleven o’clock”


Scoring Mini-Cog


Source: Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening inmulti-lingual elderly, Int J Geriatr Psychiatry 2000; 15(11):1021.

Mini-Cog

Recall = 0(+ Dementia)

Recall = 3(- Dementia)Recall = 1-2

Clock Abnormal(+ Dementia)

Clock Normal(- Dementia)

Limitations to Mini-Cog:


Visual impairment Difficulty holding writing implement Tests only executive functioning

Source: Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening

in multi-lingual elderly Int J Geriatric Psychiatry 2000; 15(11):1021.

Marion’s Screening Results:


Mini-Cog MMSE

Depression or Dementia?


Feature: Depression: Dementia:

Onset Can be acute or chronic; may coincide with life changes

Chronic, insidious and gradual

Course May have diurnal effects, (worse in AM) situational fluctuations but less than

acute confusion

Long, no diurnal effects, symptoms progressive; relatively stable over time

Duration At least 2 weeks Slow and continuous

Mood/Affect Extreme sadness, may have anxiety / irritability

Depressed or disinterested, easily distracted, inappropriate anxiety, labile

to apathy

Alertness Normal, may be reduced Generally normal

Adapted from: Edwards, N (2003) Differentiating the three D’s: Delirium, dementia and depression, MEDSURG Nursing, 12(6): 347‐357, and Foreman M., Zane D. (1996) Nursing strategies for acute confusion in elders, American Journal of Nursing 96(4): 44‐52

Depression or Dementia? (cont’d)



Attention Minimal impairment but poorly motivated Generally normal

Orientation Selective disorientation May be impaired

Memory Selective or patchy impairment – may complain about impairment

Recent & remote impaired, may confabulate to cover-up deficits

Thinking Intact but with themes of hope-lessness, helplessness, or self-deprecation. May

have difficulty concentrating and be slow to speak

Difficulty with abstraction, thoughts impoverished, judgment impaired,

words difficult to find

Hallucinations/Delusions

May have delusions (often paranoid) May have delusions, usually no hallucinations


Depression or Dementia? (cont’d)

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Activity Variable, lethargic or agitation Normal, may be decreased in later stages

Sleep Wake Cycle Disturbed, often early AM awakening Fragmented

Triggers / Etiology

Loss, genetic/familial Alzheimer’s, Multi-infarct, Alcoholism, Vitamin deficiencies, CVA, AIDS, etc.

Mental Status Testing

Failings highlighted by the patient, frequent “don’t know” answers, little

effort, frequently gives up, indifferent, does not care or attempt to find answer

Failings highlighted by family, frequent “near miss” answers, struggles with test, great effort to find an appropriate reply

Reversibility Potential Irreversible, often progressive


Behavioral symptoms associated with Dementia:

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One will occur in more than 50% of those with any dementia:AgitationAggressionVerbal or physical sexual aggressivenessDelusionsHallucinationsWanderingDepression Sleep disturbanceYelling / calling out

Causes of Behavioral Symptoms:


Damage to part of the brain (R hemisphere & R frontal lobe)

These areas of brain are mediators of social and emotional behaviors.

Behavior is no longer under conscious control of the individual.

Causes of Behavioral Symptoms:


Even when brain is no longer able to process information to understand what is going on, persons with dementia are very perceptive/sensitive emotionally.

If caregivers are anxious, hurried, angry, etc. the individual with dementia will sense this and may become distressed.

Non-pharmacological Interventionsin Nursing – (top 10)


Remain flexible

Respond to emotion, not behavior

Don’t argue

Use memory aide

Acknowledge request & respond to them

Look for reasons for behavior

Collaborate with other disciplines

Explore various solutions

Don’t take it personally!

Talk with a colleague

Nursing Interventions: Communication Tips (Top 10 )


Be calm

Focus on feelings, not facts

Pay attention to the tone of the voice

Address by preferred name

Speak slowly using simple words

Ask 1 question at a time

Avoid vague words

Don’t talk about the person as if they aren’t there

Use gestures

Be patient, flexible and understanding

Personal Care with Dignity: (Top 10)


Be flexible – adapt to their preference

Help them stay as independent as possible

Guide by using step-by-step instructions

Communicate as suggested already

Avoid rushing the person

Encourage, reassure, and praise

Watch for unspoken communication

Consider using different products (what do they use at home)

Be patient, kind and understanding

Experiment with new approaches

Response to behavioral symptoms:


Dealing with behaviors are major cause of stress and burnout for care providers

2 strategies:1. Blame the disease not the person2. Interpret behavior according to knowledge of

person’s history

Web Sites:

National Institute of Mental Health www.nimh.nih.gov

National Institute of Neurological Disorders and Stroke (NINDS) www.ninds.nih.gov

Alzheimer’s Association www.alz.org (put in zip code for most local Alzheimer’s Association office)

National Institute on Aging www.nia.nih.gov


Questions / Further Discussion


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